MEDICARE: NICHOLAS DABA PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	0057031	NY

General Provider Information

NPI Number	:	1750351474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS DABA PTA

Provider Business Mailing Address
First Line	:	PO BOX 233
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-0233
Country	:	US
Telephone Number	:	631-725-4450
Fax Number	:

Provider Business Practice Location Address
First Line	:	60A BAY ST
Second Line	:
City	:	SAG HARBOR
State	:	NY
Zip	:	11963-3106
Country	:	US
Telephone Number	:	631-725-4450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/08/2007

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